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8 Primary Prevention Primary Prevention Early Management Early Management Acute Management Acute Management Rehabilitati on & secondary prevention Rehabilitati on & secondary prevention Both downstream and upstream interventions are vital for the final population outcome in the control of a disease. It is sterile to continue opposing these two approaches. They are two sides of the same coin. What we need is an integrated approach across the continuum balancing public health interventions and health service interventions and the local organization to operationalise this as a system on the ground R. Bengoa DownstreamUpstream

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9 MESSAGE IS CLEAR : Most countries are improving in each of the boxes of the continuum but not using the potential of an integrated approach across the continuum. One of the reasons for this is that we do not have a system operating at the local level

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23 Building some sort of Local Health System BETTER CARE FOR INDIVIDUALS ( IOM ) BETTER POPULATION HEALTH LOWER GROWTH IN EXPENDITURE BY ELIMINATING INEFFICIENCIES. TACTICAL APPROACH make the link between clinical behaviour and financial consequences for clinical decisions Incentive if savings made Pathways as a tool to make that link Aim : LINK several lines of work which tend to operate separately

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24 DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME DIRECTION FOCUSING ON TRANSFORMATION OF DELIVERY CONTEXT : SOME PROMOTING COMPETITION ; OTHERS NOT. SHIFTING FROM VOLUME AND INPUTS TO VALUE LEANING ON MODELS: KP AND CCM AND OTHERS MANY BUILDING SOME SORT OF LOCAL HEALTH SYSTEM Mid-term policy perspective/ trend

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28 Create a narrative/ a common language …. PROVIDE A NARRATIVE THAT GOES BEYOND COST CONTAINMENT A NARRATIVE WICH PROVIDE A VISION AND STRUCTURE PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIROMENT THE HARDER THE EXTERNAL ENVIROMENT IS, THE GREATER THE COHESION CAN THE COMMON VISION PROVIDE R. Bengoa IN THE BASQUE COUNTRY = THE MAIN NARRATIVE IS CHRONIC DISEASES AND CLINICAL INTEGRATION

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32 Evidence increasing around a few things… Different diseases, similar needs and similar solutions Much of the evidence sends clear signals in favor of integrated care To pull this off you need patients and staff on board. It is therefore less about structural moves than about staff engagement Evidence growing but scalability still an issue

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33 THE PROCESS WILL NOT DEVELOP IN A TIDY SEQUENCE OF LINEAR STEPS. INSTEAD IT WILL PROLIFERATE VIA GROUPS OF INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS. Van de Ven 1999 THOSE INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS MUST BE SUBJECTED TO THE EVIDENCE TEST SCALABILITY…